Lack of Implemented End-of-Life Care Policy
Penalty
Summary
The deficiency involves the facility’s failure to have a developed and implemented policy and procedure for residents requiring end-of-life care. During a concurrent interview and record review with the Medical Records Manager, surveyors reviewed an undated document titled “Comfort Care and End-of-Life,” and the Medical Records Manager stated that the facility did not have an official policy and procedure in place, explaining that the comfort care policy had only been developed and had not yet been approved. In a separate interview, the Director of Nursing reported being unaware whether the facility had any policy on end-of-life care prior to the development of the Comfort Care and End-of-Life policy. As a result, the facility lacked an established, approved policy to guide staff in providing compassionate, dignified, and personalized care to residents at the end of life. No specific residents, diagnoses, or clinical conditions were identified in the report, and the deficiency is based on the absence of a formal, implemented end-of-life care policy as confirmed by facility leadership during interviews and document review.
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